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Provider: Isle of Wight NHS Trust Requires improvement

On 04 September 2019, we published a report on how well Isle of Wight NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Inadequate  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Requires improvement

Updated 4 September 2019

Our rating of the trust improved. We rated it as requires improvement because:

Inspection areas

Safe

Requires improvement

Updated 4 September 2019

  • The trust mandatory training uptake had been low in some services including for resuscitation and safeguarding.
  • There had been ongoing issues with patient flow through the hospital and over occupancy for admissions. This resulted in delays for patients to receive care and treatment and for some being nursed in non-patient bed spaces, which risked patient safety.
  • Staff did not always follow the trust's policies and procedures for recognising deteriorating patients and patients nearing the end of life.

  • Not all patients showing signs of infection were on the sepsis pathway.
  • There was a failure to deliver some national access targets including in the emergency department.
  • The trust did not always have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • The trust did not always make clear and accurate records of patients’ care and treatment.
  • The trust did not always share lessons learned with the whole team, the wider service and partner organisations.
  • We had significant concerns about the acute services. We served section 29A warning notices requiring significant improvement to be made by the trust.

  • We still had significant concerns about the community mental health services for adults of working age and the wards for older people with mental health problems. We served section 29A warning notices against both services, requiring significant improvement to be made by the trust. We also had concerns about the safety of the long stay rehabilitation wards and the acute wards for adults of working age and psychiatric intensive care unit.

  • Risk assessments of patients in mental health services were incomplete and inconsistently completed.

However:

  • The trust had introduced safety huddles and closer review of staffing since the last inspection.
  • The trust recognised, acted upon and met its legal obligations to safeguard those people at risk from abuse, neglect or exploitation.
  • The trust services controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They generally kept equipment and the premises visibly clean.
  • The service designs, maintenance and use of trust facilities including premises and vehicles where needed mostly kept people safe. There were plans for improving the emergency department design for the benefit of patients.
  • Staff were trained to use equipment and staff managed clinical waste well.
  • The trust services mainly used systems and processes to safely prescribe, administer, record and store medicines.
  • Most services recognised incidents and near misses and reported them appropriately.

Effective

Requires improvement

Updated 4 September 2019

Our rating of effective stayed the same. We rated it as requires improvement because:

  • The service did not consistently monitor the effectiveness of care and treatment. They did not consistently use the findings to make improvements and achieve good outcomes for patients.
  • Staff did not always monitor patients' nutrition and hydration needs and did not always give them enough food and drink to meet their needs and improve their health.
  • Key services were not always available seven days a week to support timely patient care.
  • The frailty pathway was under development and therefore remained a risk until established.
  • The stoke pathway did not meet national expectations for care and treatment.
  • Not all staff had received an appraisal during the past 12 months.
  • Patients in mental health services were waiting long periods for psychological therapies.

However:

  • The trust services provided care and treatment based on national guidance and evidence-based practice. Staff mostly protected the rights of patients subject to the Mental Health Act 1983.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They mostly knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Patients we spoke with told us their pain was well controlled.
  • The trust was undertaking some audits of care and treatment to improve patient outcomes.

Caring

Good

Updated 4 September 2019

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff went the extra mile providing personalised compassionate care in the Patient Transport Services and considered patients wellbeing. They ensured patients had basic food supplies when they dropped them off and they drove one patient home along the sea front as they not seen the sea for a long time.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

Responsive

Requires improvement

Updated 4 September 2019

  • Complaints were not responded to in a timely manner the themes were noted as communication, values and behaviours of staff and waiting times.
  • There were delays for some patients and families to access the service when they needed it, such as children and young people with autism requiring occupational therapy, continued to exceed national targets.
  • Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
  • The waiting lists for patients in the community for chronic pain multi-disciplinary assessment was 25-30 weeks and the chronic pain physiotherapy assessment was seven to eight months.
  • The service did not audit the expected interventional time frames for the Rapid Assessment Community Response Service (RACR).
  • Access the podiatry service for those patients assessed to be high risk did not always meet patients' needs.

However:

  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • The services were inclusive and mostly took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.

Well-led

Requires improvement

Updated 4 September 2019

Our rating of well-led improved. We rated it as requires improvement because:

  • There was no overall trust strategy for the staff to know and understand.
  • The staff survey results for 2018 showed trust staff engagement had remained lower than compared to the NHS average and for most scores was worse than average.
  • Not all staff were satisfied with the promotion of equality and diversity in the trust’s day to day work and for supporting opportunities for career progression.
  • There was insufficient support and supervision of junior doctors and this was reflected in the status of the General Medical Council enhanced surveillance.
  • There were risks with the current IT and business systems in the services, which was in need of investment, to support the services across the trust
  • There were breaches of information governance whilst these had been dealt with according to policy and the trust was due external review of these breaches in line with the legislation the trust acknowledged there were still improvements needed

However:

  • Since our last comprehensive inspection in January 2018 the trust had formed an experienced leadership team with the skills, abilities, and commitment for the potential to provide high-quality services.
  • There had been a review of governance processes and 10 week action plans to improve care and treatment across many of the services.
  • The services had their own quality strategies for improvement.
  • All staff were committed to continually learning and improving services; there were examples of innovation.
  • They recognised the training needs of managers at all levels, including themselves, and worked to provide development opportunities for the future of the organisation.
  • The board and senior leadership team had set a clear vision and the trust’s values.
  • The trust had the basis of a structure for overseeing performance, quality and risk, with board members.
  • The trust was part of the Isle of Wight Local Care Board which had worked together to provide an Isle of Wight Health and Care Sustainability Plan

Assessment of the use of resources

Use of resources summary

Inadequate

Updated 4 September 2019

Combined rating

Combined rating summary

Requires improvement
Checks on specific services

Community health services for children, young people and families

Good

Updated 4 September 2019

Our rating of this service improved. We rated it as good because:

  • We noted positive changes since our last inspection in January 2018.
  • There was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses.
  • Staff were clear about their safeguarding responsibilities and if there was a concern about a child’s wellbeing safeguarding procedures were followed and understood. All staff we spoke with had completed the appropriate level of training in safeguarding.
  • Care was planned and delivered in line with evidence-based guidance, standards and best practice and the individual needs of the child and family were met through the careful care planning.
  • Staff received annual appraisals and new staff were supported when completing their competency assessments, helping to maintain and further develop their skills and experience.
  • There was good multidisciplinary team working evident across the service including working with external agencies.
  • Parents and children gave feedback about the care and kindness received from staff, which was positive. All the children and their carers we spoke with were happy with the care and support provided by staff. We observed staff treated children, young people and their families with compassion, kindness, dignity and respect. Staff worked in partnership with children, young people and families in their care.
  • Guidance on how to make a complaint was readily available across the community children and young people’s service and was on the trust’s website.
  • Managers at local levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • In general staff gave clear advice in line with national guidance on health promotion.

However:

  • The service did not always have oversight of medicines management.
  • Some environments were not, in their design, child friendly and the service had not adapted them to meet the needs of the child and young person. However, patient’s privacy and confidentiality was not always maintained in the sexual In two areas of the service, staff did not consistently perform daily checks of a resuscitation trolley and a grab bag as per trust policy.
  • The services IT systems did not all alert staff if a child, young person or family were on a child protection plan or if there was a risk to practitioners for home visiting. Therapy staff did not always complete a safeguarding assessment when meeting a child, young person or family.
  • The 0-19 service did not have standardised protocols for recording visits on the electronic records system to ensure consistency across the service.
  • Staff did not always provide advice to children, young people and their families based on national guidance for bottle feeding.

Community-based mental health services for adults of working age

Updated 30 January 2020

We undertook an unannounced, focused inspection of community-based mental health services for adults of working age following concerns identified at our last inspection in May 2019. During that inspection, we found the provider was not fully meeting the required standards of care and issued a warning notice under section 29a of the Health and Social Care Act 2008. We undertook this inspection to check whether the provider had made the required improvements to the safety of the service. This inspection was a focussed inspection so therefore did not provide a change to the existing rating.

The provider had made the following improvements:

  • Staff caseloads were a safe size. The overall team caseloads had significantly reduced. Waiting lists had reduced and patients’ risk was reviewed regularly. The number of patients with an up to date risk assessment had increased significantly. The trust had an agreed timeframe for staff to complete risk assessments and team leaders monitored this.
  • The trust had agreed two clinical care pathways and staff used identified tools to review patients’ needs to ensure they were discharged to alternative services when ready. Team leaders were reviewing staff members caseloads to agree with staff when patients were ready for discharge.
  • The waiting time for psychological therapies had reduced.

However:

  • There was no set timeline for additional care pathways to be introduced.
  • Staff morale remained low.

Mental health crisis services and health-based places of safety

Requires improvement

Updated 4 September 2019

Our rating of this service improved. We rated it as requires improvement because:

  • Safety concerns identified at the last inspection had not been fully acted upon by managers or the trust. For example, staff had not fully completed risk assessment documentation for all patients being seen by home treatment and the health-based place of safety had not been fully refurbished.

  • Risk assessments completed by home treatment staff were brief and lacked detail. Staff manning the HBPoS were not consistently recording that they had gathered a risk history from the patient record meaning that staff were not taking all risks into account.

  • The psychiatric liaison service covering the ED had a band six vacancy which had not been filled for six months leading to one band six manning the service alone. This issue had been raised via incident reports, however the post was still vacant at the time of the inspection.

  • The home treatment team staff were not receiving Mental Health Act training although we were told that training was due to be delivered in the near future.

  • Incidents of self harm were not routinely reported through the incident reporting system. The trust policy does not state that such incidents should be reported. Learning from incidents was not consistently identified and shared with the staff team.

  • The service still did not have psychological input from a clinical psychologist resulting in patient care lacking a direct psychological focus. A psychological lead had been appointed but they were not working with teams directly.

  • The paper patient group directives (PGD) were not authorised copies, they lacked doctor, pharmacist and governance authorisation signatures. Therefore, the document trail was not compliant with the Human Medicines regulations 2012. However, we could find no evidence that staff did not know the correct process or hat harm had been caused.

  • The HBPoS had not been refurbished following our last inspection and was still unfit for purpose. This results in patients were detained in an area which was poorly decorated and lacked an appropriate room in which to be assessed.

However:

  • Staff were professional, caring and supportive. The interactions we observed demonstrated a positive attitude towards patients and their families.

  • Patients we spoke with were positive about staff and services. They felt that they were treated with respect and were involved in decisions about their care.

  • Patients and carers were given details of expected visits and had a number to call 24 hours a day in the event of a crisis.

  • Several team members were trained as DBT therapists which helped ensure a psychological approach was taken when meeting patient need.

Community health services for adults

Good

Updated 4 September 2019

Our rating of this service improved. We rated it as good because:

  • We noted positive changes since our last inspection in January 2018.
  • We found monitoring, analysis and feedback of safety issues by the senior team took place in a comprehensive and timely way, this was an improvement since our last inspection.
  • Staff told us there had been change and improvement in the culture of senior leaders across the division.
  • The IT skills and the use of the new electronic system had been a challenge for staff. Since our last inspection, extra training and support had been completed and we saw how community nursing teams used the electronic system safely in their day to day care planning and to complete audits.
  • The majority of patients had good outcomes because they received effective care and treatment.
  • The majority of people’s needs were met through the way the services were organised and delivered.
  • Community multidisciplinary staff in different teams worked together supporting patients to improve their health and wellbeing.
  • The community team identified and captured risk with clearly defined mitigation and action plans. While there was a process for the escalation of high risk it was not clear all such risks had been escalated.

However:

  • Some of the mandatory training levels although improved since our last inspection, were still under the trust target, for example training on medicines management, practical assessment.
  • Staff did not always fully complete the paper medicines administration record.
  • Clinical supervision was available and was being utilised, however the service had not yet devised mechanisms for monitoring supervision levels.
  • Generally, the service had systems and processes to ensure patient information was kept confidential and secure. However, the Arthur Webster clinic did not always store records securely.
  • Access to assessment and treatment did not always meet the patients’ needs.

Emergency operations centre (EOC)

Requires improvement

Updated 4 September 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The emergency operations centre was still in the early stages of embedding new governance structures, systems and processes into the service. Therefore, it was too early to fully establish whether new strategies and quality improvement programmes were effective or working well.
  • The service did not always meet the Ambulance Response Programme quality indicators for the time to answer each call. We found there was no long-term service planning or solution identified to tackle increased demand. Resources were deployed by dispatchers by 9.30am on both days of our inspection, causing delays to treatment.
  • There was still a lack of sustainable staffing levels for clinical support staff on the night time shift and this had not improved since our last inspection.
  • The audit team did not have access to the new CAD system within their department, so had to move when asked to assist with taking calls.

However:

  • The service had introduced a new CAD system, and this meant better quality real time information was now available for the service to monitor trends and themes. This was an improvement since our last inspection.
  • The service had recruited more performance support officers, clinicians and dispatchers. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff cared for patients with compassion and took account of their individual needs. Feedback from patients confirmed that staff treated them well and with kindness.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. This was an improvement since our last inspection.
  • Staff had received training in the Mental Capacity Act 2005 and the compliance rate for mandatory training was 90%. This was an improvement since our last inspection.
  • The service policies were up to date and standard operating procedures (SOP) had been reviewed and updated. This was an improvement since our last inspection.
  • There was a new meal break policy and staff now received 30 minute meal breaks during their shifts. This was an improvement since our last inspection.

Patient transport services

Requires improvement

Updated 4 September 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not control infection risk well. Ambulances were not cleaned effectively to ensure the risk of cross contamination issues were minimised.
  • Managers could not routinely monitor the performance of the service. Available computer systems did not support the collection and analysis of information to allow for the continuous improvement and delivery of a quality service.
  • Risk management processes had not always identified and escalated risks appropriately to ensure mitigating action could be taken to minimise risks associated with service delivery.

However:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment and ensured patients had enough to eat and drink. Managers made sure staff were competent for their role Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with extreme compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers taking action to ensure their individual needs were known and met.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for transport.
  • Leaders ran services well and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Acute wards for adults of working age and psychiatric intensive care units

Requires improvement

Updated 4 September 2019

Our rating of this service went down. We rated it as requires improvement because:

  • Staff on both wards did not undertake post rapid tranquilisation checks to detect any adverse effects of the medication as frequently as recommended by the National Institute of Health and Care Excellence. Patients could be put at serious risk of harm if side effects are not responded to in a timely manner.
  • Staff on Osbourne ward did not update risk assessments following incidents involving patients. Staff did not document the rationale for using prone restraint as an intervention or document the length of time patients were in a prone position during restraint.
  • Staff did not give appropriate consideration to reviewing and reducing blanket restrictions on the wards. Areas on Seagrove ward such as the male lounge, the female lounge and the garden had limited access and could only be accessed following risk assessment and/or supervision from staff. The trust had not prioritised estates work to remove ligature anchor points which meant patients had limited access to these areas.
  • The trust did not provide psychologically based therapies as recommended by the National Institute of Mental Health Excellence.
  • Patients’ rights were not always explained as frequently as they should have been.
  • Patients sometimes had to be transferred to other wards such as the rehabilitation ward and the older person’s wards due to beds not always being available for patients requiring admission.
  • Staff on Osbourne ward did not consistently ensure that vision panels on patients’ doors were left closed when patients had expressed that preference which compromised their privacy.

However:

  • Staff on both wards completed regular checks of the environment to make sure it was safe.
  • Staff on both wards ensured the clinic rooms contained all the equipment necessary. Resuscitation bags and equipment was checked accurately and regularly. The seclusion suite was now fit for purpose and met the requirements of the Mental Health Act code of practice.
  • Staff on both wards knew how to recognise abuse and were aware of how to record and report it.
  • Staff used recognised rating scales to assess and record severity and outcomes.
  • Staff treated patients with compassion and kindness. Staff involved patients in care planning and risk assessment and encouraged families to visit and give feedback.
  • Each patient had their own bedroom with an ensuite bathroom and could keep their personal belongings safe.

  • Leaders were well respected. Staff felt supported and valued and morale across both wards was good.

Long stay or rehabilitation mental health wards for working age adults

Requires improvement

Updated 4 September 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not always provide safe care to patients. For example, patients admitted to the ward that should have been cared for on acute wards did not always receive an assessment of their needs and risk before admission, and their risk assessments did not recognise and mitigate for all the risks present within the environment. The service had no protocols or policies to support Woodlands staff to manage acute patients. Staff were experienced in caring for patients with mental health needs, but staffing numbers did not always enable staff to provide adequate support to both the acutely unwell, and rehabilitation patients present on the ward.
  • Patients did not receive the full range of recommended care and treatment interventions suitable for patients requiring rehabilitation care and consistent with national guidance on best practice. For example, patients were not able to store medicines in their room and self-administer in preparation for discharge, and the ward had only recently recruited a psychologist, and was yet to embed psychological input into the wards treatment programme .
  • Ward teams did not have access to the information they needed to improve the service and provide effective care. For example, the service did not have any clinical key performance indicators to evaluate the wards effectiveness, and the service did not track and report when patients’ discharges had been delayed.
  • Leaders did not ensure all staff received regular one to one or group supervision, and not all staff felt supported. Staff were not provided with training on how to manage and prevent violence and aggression, which at times would be required to safely manage the higher risk patients from the acute wards.

However:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. Staff developed holistic and recovery-orientated care plans.
  • The ward team included or had access to the full range of specialists, having recently recruited a psychologist, required to meet the needs of patients on the ward. Managers ensured staff received an annual appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

Emergency and urgent care

Good

Updated 4 September 2019

Our rating of this service improved. We rated it as good because:

  • Managers at all levels in the service were developing the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • Managers across the service promoted a positive culture that supported and valued staff. The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • Staff cared for patients with compassion and took account of their individual needs. Feedback from patients confirmed that staff treated them well and with kindness.
  • The service had a process for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • There was a new meal break policy and staff now received 30-minute meal breaks during their shifts. This was an improvement since our last inspection.

However:

  • The service strived to improve the quality of its services. However, we found issues regarding the governance and oversight of medicines management and some concerns regarding security of paper patient records.
  • Systems to analyse, and use the information were now available to the service to support service development were under development. New reporting and governance system were in the early stages of being embedded into the service, Therefore, it was too early to fully establish whether new strategies and quality improvement programmes were effective or working well.
  • The long-term plans for divisional and reporting structure under which the ambulance service would be managed were not yet clear.

Wards for older people with mental health problems

Inadequate

Updated 4 September 2019

Our rating of this service stayed the same. We rated it as inadequate because:

Following our previous inspection in January 2018, CQC rated wards for older people with mental health problems as inadequate in safe and well-led key questions, requires improvement in effective and responsive key questions and good for the caring key question.

At the inspection in 2018 we told the trust they MUST:

• The trust must ensure Shackleton ward has a dedicated female-only day room which male patients do not enter. (Regulation 10)

During this inspection, we found that Shackleton ward now has a female-only day room that male patients do not enter.

• The trust must ensure staffing is at a safe level on Shackleton ward and that running of electro-convulsive therapy clinics does not adversely affect all wards minimum staff levels. (Regulation 18)

During this inspection, we found that staffing levels on Shackleton ward had improved and the running of electroconvulsive therapy clinics did not have an impact on staffing on the ward.

• The trust must ensure staff follow post-rapid tranquilisation protocols. (Regulation 12)

During this inspection, we found that staff were following post rapid tranquilisation protocols.

• The trust must ensure they comply with legislation around the seclusion of patients on the ward. (Regulation 12)

During this inspection, we found that staff were compliant with legislation around the seclusion of patients on the ward.

• The trust must ensure they comply with medicines management legalisation including the storage of controlled drugs. (Regulation 12)

During this inspection, we found that staff complied with medicines management in relation to the storage of controlled drugs.

• The trust must ensure staff are inducted, supervised and appraised. (Regulation 18)

During this inspection we found that staff on Afton ward received regular supervision. However, staff supervision levels were not sufficient on Shackleton ward.

• The trust must ensure staff apply the principles of the Mental Capacity Act and support patients to make decisions about their care. Patients must be cared for in the least restrictive way (Regulation 11)

During this inspection we found that staff on both wards were not correctly applying the Mental Capacity Act in relation to Deprivation of Liberty Safeguards.

• The trust must ensure patients can access fresh air. (Regulation 10)

During this inspection, we found that staff were supporting patients to access fresh air on a regular basis.

• The trust must ensure patients have access to food and fluids (Regulation 14)

During this inspection, we found that patients had access to food and fluids including snacks throughout the day.

• The trust must ensure patients’ records are stored securely. (Regulation 17)

During this inspection, we found that staff on Shackleton ward did not keep patients’ confidential records safe.

• The trust must ensure that when staff are in leadership positions, they are trained and supported to carry out their roles effectively. (Regulation18)

During this inspection, we found that managers on Shackleton ward had not been supported by the trust to carry out their roles effectively.

• The trust must ensure the privacy and dignity of patients on Shackleton ward is maintained, by addressing the windows. (Regulation 9)

During this inspection, we found the trust has applied a film to the windows which ensured patients’ privacy and dignity.

  • Following our inspection in June 2019, we served a warning notice as we had serious concerns about the care and treatment of patients of patients using the service. In addition, the trust had not made a number of improvements to safety that we told it that it must make at the previous inspection We required the trust to make significant improvements to the safety of the service by 26 July 2019. In response to our concerns the trust told us they would take immediate steps to keep patients safe on the wards. On 6 August 2019, we completed a follow-up inspection to determine if the trust had met the requirements of the warning notice. We found that although there had been some improvements, the trust had not met all the requirements of the warning notice. Following the inspection, the trust took the decision to close the ward to new admissions. Patients on the ward during the follow-up inspection were discharged to other placements and the ward was empty and closed to admissions. The trust informed us they would be discussing future service provision of Shackleton ward with partners and stakeholders and would not reopen without notifying CQC.  
  • Risk assessment on Shackleton ward were not detailed enough to ensure all staff were aware of and could manage all risks. Staff did not assess, monitor or manage risks to people who use the service. Staff had not been supported to manage the ligature risks on the ward and 10 days following the reopening of the ward, staff were still unsure of where the ligature risks existed on the ward. Staff on Shackleton did not prioritise the security of the ward by keeping the clinic room locked and by storing the ward keys securely.
  • Staff on Afton ward did not effectively identify and manage patients’ physical health needs. Staff did not complete holistic personalised goal focussed care plans to support care delivery.
  • The trust did not ensure patients on Shackleton ward received therapies in line with national guidance. There was no psychological therapy or occupational therapy available to patients and we were not assured that there was any meaningful activities or engagement being delivered on the ward. There were no activities on the day of our inspection or follow-up inspection.
  • Staff on both wards did not make appropriate referrals under the Deprivation of Liberty Safeguards. Staff on Shackleton ward did not consider best interests and administering medicines covertly to a patient with ongoing infections that had been refusing treatment for four days. Staff on Afton ward had not recorded, assessed and documented mental capacity status in relation to medicines. At the follow-up inspection, a patient had a covert medication plan in place but did not have a mental capacity assessment or best interests meeting recorded.
  • Staff on Shackleton ward did not keep patients’ confidential records safe. This remained the case at the follow-up inspection. In the communal area of the ward we found a filing cabinet containing confidential records unlocked.
  • On Afton ward, clinic room fridge temperatures had been outside of the recommended temperature range and no actions had been identified. On both wards, oxygen was stored in the clinic room without a sign on the door to inform fire officers that compressed gas was stored there.
  • On Shackleton ward the governance arrangements and their purpose were unclear. Governance arrangements are important to ensure managers have oversight of key items such as the strategy, clinical audit, complaints, incidents and safeguarding are reviewed and learned from.
  • Leadership on Shackleton ward was poor. Staff were unaware of the ward action plan for reopening Shackleton ward. There was a lack of clinical managerial support for managers. trust leaders were not visible on the ward.

However,

  • Both wards had undergone significant improvements to the environment which had improved some standards of care. There was now a female only lounge on Shackleton ward that was only used by females. The garden on Afton ward had reopened since the last inspection in January 2018, it was unlocked throughout the day, contained wheelchair friendly flowerbeds and there was a range of plants, flowers and vegetables. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Each patient had their own bedroom with an ensuite bathroom and could keep their personal belongings safe.
  • Patients on Shackleton ward were regularly taken to the garden for fresh air.
  • Staff on both wards showed kindness and respect towards patients. Patients said that staff were friendly and kind. Staff on Afton ward had gone the extra mile to understand patients’ individual needs and preferences.
  • Staff on Afton ward supported patients with a range of needs that fell outside of the scope of functional mental illness. Staff had changed and adapted their training to ensure they met patients’ needs.
  • On both wards, the food was of a good quality and patients could make hot drinks and snacks at any time.
  • Staffing levels on Shackleton ward had improved.
  • Staff on Shackleton ward were no longer secluding patients in the corridor and understood the legislation around seclusion in the Mental Health Act code of practice.
  • Medicines management on Shackleton ward had improved, controlled drugs were stored correctly and staff followed national guidance on physical health monitoring post administration of rapid tranquilisation. During the follow-up inspection the clinic room remained locked throughout the day and the ward keys were stored securely. We also found that the ward manager was now being adequately supported by other managers in the trust.

Specialist community mental health services for children and young people

Good

Updated 6 June 2018

Our rating of this service improved. We rated it as good because:

  • Staff had access to up to date, accurate and comprehensive information about children and young people in their care and treatment plans. They ensured that care plans and crisis plans were up to date and comprehensive, assisting the teams’ deliver of safe care and treatment to young people. Staff members ensured there was an effective system in place to assess the risks to all young people
  • The staff team had reviewed and improved the way they reported incidents. They ensured incidents were consistently reported and there was learning from each incident.
  • Staff involved children and young people and those close to them in decisions about their care and treatment. Children and young people spoken with were very positive about the care and treatment they received. The team listened to feedback from parents and young people, supported them and made changes because of the feedback.
  • There was no waiting list for the service and young people were seen quickly.
  • Staff were well trained to carry out their roles. There was suitably skilled and experienced staff to support children and young people’s needs.
  • The manager promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff morale was good and staff felt positive about their team.

However:

  • Young people could not always access the service when they needed it. There was no out of hours provision for young people. Young people admitted to hospital at the weekend had to wait until the following Monday before being assessed by CAMHS staff.
  • The service did not deliver all the psychological therapies recommended by NICE.
  • There was no provision for young people with attention deficit hyperactivity disorder or autism spectrum disorder. Whilst there were discussions with the clinical commissioning group about the pathway, these young people were excluded from the service and had been for several years.
  • The service did not ensure that the premises were safe for children and young people. They had access to domestic knives in the unlocked kitchen.
  • The manager did not ensure staff were competent for their roles because staff members did not all receive sufficient regular one to one managerial supervision.
  • The staff team did not treat all complaints seriously because they did not investigate verbal complaints from children, young people or their families.

Community mental health services with learning disabilities or autism

Good

Updated 6 June 2018

Our rating of this service stayed the same. We rated it as good because:

  • There was evidence that the waiting list was monitored and patients were assessed and prioritised according to risk. Staff could see Service users quickly if there were any concerns about any deterioration in their presentation.
  • Staff delivered a range of evidenced based care and treatment interventions that were suitable for people with a learning disability. Care plans were personalised, holistic and considered the service user’s needs.
  • Staff discussed risk in multi-disciplinary team (MDT) meetings and responded promptly to the service users need. Risk assessments were individual to each service user.
  • Staff demonstrated a clear focus on service users physical health needs and considered its impact in their interventions in all records reviewed
  • All staff had received an annual appraisal. Staff appraisals included conversations about career development and how it could be supported.
  • Service users we spoke with said that staff treated them with dignity and respect and understood their care needs. Staff involved families and carers to understand service users likes, dislikes and specific needs where appropriate. All service users and carers reported feeling involved in their care.
  • All areas were clean with good furnishings.

However:

  • Service users were not having standardised risk assessments completed. A clear picture of a service users risks was not immediately apparent in the electronic notes. Information was not easily accessible on the electronic records system and was stored in different areas. Clinical information about the service user was difficult to find.
  • Regular management supervision which included caseload supervision was not formally documented. Management supervision was not completed monthly in line with the trust supervision policy.
  • Mental Health Act (MHA) specific training was not provided.
  • Staff had not been involved with the transformation plan. Staff reported feeling out of the loop and did not know what was happening.
  • Conflicts between staff were not managed quickly by senior managers
  • The service was not taking positive action to support the national Transforming Care programme

Community health inpatient services

Requires improvement

Updated 12 April 2017

We rated the service as requires improvement because:

  • Medicines were not stored safety and securely which may pose risks to patients.
  • Equipment was not always managed safely and in line with the trust’s operating procedures. These included pressure relieving equipment which had not been serviced.
  • There was a lack of lifting equipment which impacted on the care and treatment people were receiving.
  • Patents’ records were not stored safely which posed risks of data protection breaches.
  • Patients told us that at times staffing caused delays to the timeliness of care.
  • Some of the nurses did not have a clear understanding of the Mental Capacity Act 2005 (MCA). Mandatory MCA and Deprivation of Liberty Safeguards (DoLS) training for all registered nurses was below the trust target, which may impact negatively on care. Appraisal compliance was below the trust target on the stroke unit and general rehabilitation unit.
  • Therapy staff did not work seven days a week so stroke patients were not always able to have specialist assessments within 72 hours.
  • Patients were sometimes moved at night, and experienced delays leaving hospital.
  • There were high levels of nursing staff sickness on the stroke unit.
  • Managing risks was not robust. Senior staff were not always aware of the current risks and issues, so there was no plan to address them.
  • Formal feedback about the stroke service was limited from patients and their families.

However

  • Staff understood their responsibilities to raise concerns and report incidents, and learning actions were identified.
  • The trust took part in local and national audits to measure and promote improved outcomes for patients.
  • Patient pain was managed effectively, and patients varied dietary and nutritional needs were met.
  • Since the inspection in September 2014, the service had developed admission criteria for the general rehabilitation unit, which supported the staff in admitting appropriate patients.
  • On the general rehabilitation unit safeguarding adult level 3 training was 100%.
  • There was a multidisciplinary approach on the stroke unit and the general rehabilitation unit. Nursing, therapy and medical staff were caring, compassionate and patient centred in their approach.
  • Patients were involved in making decisions about their care and treatment.
  • There was evidence the trust used learning from complaints to improve the quality of care.
  • The service promoted equality, supported people to be independent and met the needs of people in vulnerable circumstances.

Substance misuse services

Good

Updated 12 April 2017

We rated this service as good because.

  • The building was accessible, with a clean and well-maintained environment. The clinic room contained appropriate equipment for physical health monitoring; for example, there was a couch and an electrocardiogram machine to check clients’ heart rhythm and electrical activity.
  • There were sufficient numbers of staff to meet the needs and safety of the clients using the service. The trust provided all staff with mandatory training. There was a robust staff induction programme and staff attended mandatory training. Staff morale was good despite recent pressures of redesign and reductions in staffing.
  • Staff interacted with clients in a respectful and supportive way. Staff were warm, kind, respectful, enthusiastic and positive. Full risk assessments and risk management plans were in place. They were clear and comprehensive. Staff discussed risk with partner agencies on an ongoing basis. Staff used a robust assessment tool called ‘client evaluation of self’ at the point of referral. All the care records we reviewed were comprehensive and clear. Staff assessed the physical and mental health of the clients and continued to review and update the records. Where appropriate, staff involved clients and family members fully in care planning.

  • Staff supported clients in line with ‘drug misuse and dependence: UK guidelines on clinical management (2007)’ during detoxification treatment, and followed the trust’s ‘operational guidelines for alcohol and opioid prescribing’ as well as the Royal College of General Practitioners guidelines (first edition 2011). All the guidelines for interventions and prescribing pathways were adapted from appropriate National Institute of Clinical Excellence (NICE) guidelines. Prescribers recorded appointments and outcomes on the electronic records and a client’s prescribing pathway was clear and legible.

  • There was a good choice of activities to suit individual needs such as the 12-step programme, and informal group sessions designed to help clients discuss and improve skills in coping with dependency and avoiding relapse, although the service did not have access to a psychologist

  • The provider had a robust incident reporting process. Staff knew how to report incidents. Staff were open and honest when things went wrong.

However,

  • Although the service had a detailed health and safety environmental risk assessment, including fire risk assessments, and staff told us their policy was to review the document annually, the environmental risk assessment had not been updated since January 2015 and staff had not monitored progress against the identified actions. Staff had also not updated all other policies, including for children visiting the service.

  • Although supervision took place, this was not regular and documentation was of poor quality.

  • Staff did not formally document a daily handover of client information at the end of each shift, which meant staff did not evidence how they monitored client progress.

  • Staff did not have a clear system in place for documenting when they administered medication

  • The service operated in isolation from the rest of the trust and staff did not feel the service was an integral part of the trust.